How would you investigate a 16-year old patient admitted with repeated episodes of haematemesis?

I. Initial Assessment and Stabilization

The first priority is to assess and stabilize the patient’s hemodynamic status. This involves:

• Airway, Breathing, Circulation (ABC) assessment: Ensuring a patent airway, adequate breathing, and stable circulation.
• Vital Signs Monitoring: Continuous monitoring of heart rate, blood pressure, respiratory rate, and oxygen saturation.
• Intravenous Access: Establishing two large-bore intravenous lines for fluid resuscitation and blood transfusion if necessary.
• Fluid Resuscitation: Initiating intravenous fluid resuscitation with crystalloids (e.g., normal saline or Ringer’s lactate) to restore intravascular volume.
• Blood Transfusion: Transfusing packed red blood cells if the patient is significantly anaemic (haemoglobin <7 g/dL or symptomatic).

II. History Taking

A detailed history is essential to narrow down the potential causes. Key areas to explore include:

• Presenting Complaint: Detailed description of the haematemesis – amount, colour (bright red vs. coffee-ground emesis), frequency, and associated symptoms (e.g., abdominal pain, dizziness, melena).
• Past Medical History: Any previous gastrointestinal problems, bleeding disorders, or chronic illnesses.
• Medication History: Use of nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, or other medications that can increase the risk of bleeding.
• Family History: History of gastrointestinal bleeding, peptic ulcer disease, or bleeding disorders in the family.
• Social History: Smoking, alcohol consumption (though less common in this age group), and any history of stress or psychological factors.
• Dietary History: Recent dietary changes or ingestion of corrosive substances.

III. Physical Examination

A thorough physical examination should be performed, focusing on:

• General Appearance: Assessing the patient’s level of consciousness, pallor, and signs of shock.
• Abdominal Examination: Palpating for tenderness, guarding, or organomegaly. Auscultating for bowel sounds.
• Vital Signs: Re-assessing and documenting vital signs.
• Skin Examination: Looking for signs of bleeding disorders (e.g., petechiae, ecchymoses).
• Rectal Examination: Assessing for melena (black, tarry stools) and occult blood.

IV. Laboratory Investigations

The following laboratory tests are crucial:

• Complete Blood Count (CBC): To assess haemoglobin levels, haematocrit, and platelet count.
• Coagulation Studies: Prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) to evaluate clotting function.
• Liver Function Tests (LFTs): To assess liver function and rule out liver disease as a cause of bleeding.
• Renal Function Tests (RFTs): To assess kidney function.
• Blood Group and Crossmatch: In preparation for potential blood transfusion.
• Stool for Occult Blood: To confirm the presence of blood in the stool.
• Helicobacter pylori Testing: Serology or urea breath test to detect H. pylori infection, a common cause of peptic ulcers.

V. Endoscopic Investigations

Endoscopy is the gold standard for diagnosing upper gastrointestinal bleeding.

• Upper Endoscopy (Esophagogastroduodenoscopy - EGD): Allows direct visualization of the oesophagus, stomach, and duodenum to identify the source of bleeding (e.g., ulcers, erosions, Mallory-Weiss tears, varices). Biopsies can be taken for histological examination.

VI. Imaging Studies

Imaging studies are generally less helpful in acute upper GI bleeding but may be considered in specific situations:

• Abdominal X-ray: May be useful to rule out perforation.
• CT Scan: Can be considered if the source of bleeding is unclear or if there is suspicion of other intra-abdominal pathology.
• Capsule Endoscopy: May be considered for obscure GI bleeding if EGD and colonoscopy are negative.